[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR422.111]



[Page 997-999]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 422_MEDICARE ADVANTAGE PROGRAM--Table of Contents

 

             Subpart C_Benefits and Beneficiary Protections

 

Sec. 422.111  Disclosure requirements.



    (a) Detailed description. An MA organization must disclose the 

information specified in paragraph (b) of this section--

    (1) To each enrollee electing an MA plan it offers;

    (2) In clear, accurate, and standardized form; and

    (3) At the time of enrollment and at least annually thereafter.

    (b) Content of plan description. The description must include the 

following information:

    (1) Service area. The MA plan's service area and any enrollment 

continuation area.

    (2) Benefits. The benefits offered under a plan, including 

applicable conditions and limitations, premiums and cost-sharing (such 

as copayments, deductibles, and coinsurance) and any other conditions 

associated with receipt or use of benefits; and to the extent it offers 

Part D as an MA-PD plan, the information in Sec. 423.128 of this 

chapter; and for purposes of comparison-

    (i) The benefits offered under original Medicare, including the 

content specified in paragraph (f)(1) of this section;

    (ii) For an MA MSA plan, the benefits under other types of MA plans; 

and

    (iii) The availability of the Medicare hospice option and any 

approved hospices in the service area, including those the MA 

organization owns, controls, or has a financial interest in.

    (3) Access. (i) The number, mix, and distribution (addresses) of 

providers from whom enrollees may reasonably be expected to obtain 

services; any out-of network coverage; any point-of-service option, 

including the supplemental premium for that option; and how the MA 

organization meets the requirements of Sec. 422.112 and Sec. 422.114 

for access to services offered under the plan.



[[Page 998]]



    (ii) The process MA regional plan enrollees should follow to secure 

in-network cost sharing when covered services are not readily available 

from contracted network providers.

    (4) Out-of-area coverage provided under the plan, including coverage 

provided to individuals eligible to enroll in the plan under Sec. 

422.50(a)(3)(ii).

    (5) Emergency coverage. Coverage of emergency services, including--

    (i) Explanation of what constitutes an emergency, referencing the 

definitions of emergency services and emergency medical condition at 

Sec. 422.113;

    (ii) The appropriate use of emergency services, stating that prior 

authorization cannot be required;

    (iii) The process and procedures for obtaining emergency services, 

including use of the 911 telephone system or its local equivalent; and

    (iv) The locations where emergency care can be obtained and other 

locations at which contracting physicians and hospitals provide 

emergency services and post-stabilization care included in the MA plan.

    (6) Supplemental benefits. Any mandatory or optional supplemental 

benefits and the premium for those benefits.

    (7) Prior authorization and review rules. Prior authorization rules 

and other review requirements that must be met in order to ensure 

payment for the services. The MA organization must instruct enrollees 

that, in cases where noncontracting providers submit a bill directly to 

the enrollee, the enrollee should not pay the bill, but submit it to the 

MA organization for processing and determination of enrollee liability, 

if any.

    (8) Grievance and appeals procedures. All grievance and appeals 

rights and procedures.

    (9) Quality improvement program. A description of the quality 

improvement program required under Sec. 422.152.

    (10) Disenrollment rights and responsibilities.

    (11) Catastrophic caps and single deductible. MA organizations 

sponsoring MA regional plans are required to provide enrollees a 

description of the catastrophic stop-loss coverage and single deductible 

(if any) applicable under the plan.

    (c) Disclosure upon request. Upon request of an individual eligible 

to elect an MA plan, an MA organization must provide to the individual 

the following information:

    (1) The information required in paragraph (f) of this section.

    (2) The procedures the organization uses to control utilization of 

services and expenditures.

    (3) The number of disputes, and the disposition in the aggregate, in 

a manner and form described by the Secretary. Such disputes shall be 

categorized as

    (i) Grievances according to Sec. 422.564; and

    (ii) Appeals according to Sec. 422.578 et. seq.

    (4) A summary description of the method of compensation for 

physicians.

    (5) Financial condition of the MA organization, including the most 

recently audited information regarding, at least, a description of the 

financial condition of the MA organization offering the plan.

    (d) Changes in rules. If an MA organization intends to change its 

rules for an MA plan, it must:

    (1) Submit the changes for CMS review under the procedures of Sec. 

422.80.

    (2) For changes that take effect on January 1, notify all enrollees 

at least 15 days before the beginning of the Annual Coordinated Election 

Period defined in section 1851(e)(3)(B) of the Act.

    (3) For all other changes, notify all enrollees at least 30 days 

before the intended effective date of the changes.

    (e) Changes to provider network. The MA organization must make a 

good faith effort to provide written notice of a termination of a 

contracted provider at least 30 calendar days before the termination 

effective date to all enrollees who are patients seen on a regular basis 

by the provider whose contract is terminating, irrespective of whether 

the termination was for cause or without cause. When a contract 

termination involves a primary care professional, all enrollees who are 

patients of that primary care professional must be notified.

    (f) Disclosable information--(1) Benefits under original Medicare. 

(i) Covered services.



[[Page 999]]



    (ii) Beneficiary cost-sharing, such as deductibles, coinsurance, and 

copayment amounts.

    (iii) Any beneficiary liability for balance billing.

    (2) Enrollment procedures. Information and instructions on how to 

exercise election options under this subpart.

    (3) Rights. A general description of procedural rights (including 

grievance and appeals procedures) under original Medicare and the MA 

program and the right to be protected against discrimination based on 

factors related to health status in accordance with Sec. 422.110.

    (4) Potential for contract termination. The fact that an MA 

organization may terminate or refuse to renew its contract, or reduce 

the service area included in its contract, and the effect that any of 

those actions may have on individuals enrolled in that organization's MA 

plan.

    (5) Benefits. (i) Covered services beyond those provided under 

original Medicare.

    (ii) Any beneficiary cost-sharing.

    (iii) Any maximum limitations on out-of-pocket expenses.

    (iv) In the case of an MA MSA plan, the amount of the annual MSA 

deposit.

    (v) The extent to which an enrollee may obtain benefits through out-

of-network health care providers.

    (vi) The types of providers that participate in the plan's network 

and the extent to which an enrollee may select among those providers.

    (vii) The coverage of emergency and urgently needed services.

    (6) Premiums. (i) The MA monthly basic beneficiary premiums.

    (ii) The MA monthly supplemental beneficiary premium.

    (iii) The reduction in Part B premiums, if any.

    (7) The plan's service area.

    (8) Quality and performance indicators for benefits under a plan to 

the extent they are available as follows (and how they compare with 

indicators under original Medicare):

    (i) Disenrollment rates for Medicare enrollees for the 2 previous 

years, excluding disenrollment due to death or moving outside the plan's 

service area, calculated according to CMS guidelines.

    (ii) Medicare enrollee satisfaction.

    (iii) Health outcomes.

    (iv) Plan-level appeal data.

    (v) The recent record of plan compliance with the requirements of 

this part, as determined by the Secretary.

    (vi) Other performance indicators.

    (9) Supplemental benefits. Whether the plan offers mandatory and 

optional supplemental benefits, including any reductions in cost sharing 

offered as a mandatory supplemental benefit as permitted under section 

1852(a)(3) of the Act (and implementing regulations at Sec. 422.102) 

and the terms, conditions, and premiums for those benefits.

    (10) The names, addresses, and phone numbers of contracted providers 

from whom the enrollee may obtain in-network coverage in other parts of 

the service area.

    (11) If an MA organization exercises the option in Sec. 

422.101(b)(3) or (b)(4) related to an MA plan, then it must make the 

local coverage determination that applies to members of that plan 

readily available to providers, including through a web site on the 

Internet.

    (12) To the extent an MA organization has a web site or provides MA 

plan information through the Internet, then it must also post copies of 

its Evidence of Coverage, Summary of Benefits and information (names, 

addresses, phone numbers, specialty) on the network of contracted 

providers on an Internet web site. Such posting does not relieve the MA 

organization of its responsibility under Sec. 422.111(a) to provide 

hard copies to enrollees.



[63 FR 35077, June 26, 1998, as amended at 64 FR 7980, Feb. 17, 1999; 65 

FR 40321, June 29, 2000; 68 FR 50857, Aug. 22, 2003; 70 FR 4722, Jan. 

28, 2005; 70 FR 52026, Sept. 1, 2005]